Resuscitation Task Force on Resuscitation Section editors:

(1)

Resuscitation

Task Force on Resuscitation

Section editors: Paul Pepe and Joost Bierens

6.1 Overview 312

Paul Pepe and Joost Bierens 6.2

Consensus and Recommendations 314 Paul Pepe and Joost Bierens

6.3 The Critical Role of Lay Persons

and Their Actions in Drowning Incidents 323 Jane Wigginton, Paul Pepe, Denise Mann, David Persse and Paul Sirbaugh

6.4 Basic Life Support for Drowning Victims 327 Ahamed Idris

6.5 Automated External Defibrillators in the Aquatic Environment 331 Steve Beerman and Bo Løfgren

6.6 Positioning the Drowning Victim 336 David Szpilman and Anthony Handley 6.7

First Aid Courses for the Aquatic Environment 342 David Szpilman, Luiz Morizot-Leite, Wiebe de Vries, Justin Scarr, Steve Beerman, Fernando Martinho, Luiz Smoris and Bo Løfgren

6.8 Advanced Life Support 348 Volker Wenzel and Paul Pepe

SECTION 6

(2)

Alfred Bove and Rienk Rienks 6.10

Paediatric Considerations in Drowning 356

Robyn Meyer, Andreas Theodorou and Robert Berg 6.11

Termination of Resuscitation Efforts in Drowning 363 Martin Nemiroff and Paul Pepe

6.12 Unusual Circumstances of Drowning 368 Peter Morley

6.13 A Case Report of an Extreme Situation 372 Martin Stotz and Wolfgang Ummenhofer 6.14

A Case Report of a Successful Resuscitation from Accidental Hypothermia of 22°C and Submersion with Circulatory Arrest 374 Gert-Jan Scheffer

6.15 A Care Report of 22-Minute Submersion in Warm Water Without Sequelae 375 David Szpilman

6.16 Recommended Guidelines for Uniform Reporting of Data from Drowning: The Utstein Style 377

Ahamed Idris, Robert Berg, Joost Bierens, Leo Bossaert,

Christine Branche, Andrea Gabrielli, Shirley Graves,

Anthony Handley, Robyn Hoelle, Peter Morley, Linda Papa,

Paul Pepe, Linda Quan, David Szpilman, Jane Wigginton and

Jerome Modell

(3)

Task Force Chairs

▬ Paul Pepe

▬ Joost Bierens

Task Force Members

▬ Robert Berg

▬ Leo Bossaert

▬ Anthony Handley

▬ Ahamed Idris

▬ Peter Morley

▬ Martin Nemiroff

▬ Volker Wenzel

▬ Jane Wigginton

Other Contributors

▬ Steve Beerman

▬ Alfred Bove

▬ Christine Branche

▬ Andrea Gabrielli

▬ Shirley Graves

▬ Robyn Hoelle

▬ Bo Løfgren

▬ Denise Mann

▬ Fernando Martinho

▬ Robyn Meyer

▬ Jerome Modell

▬ Luiz Morizot-Leite

▬ Linda Papa

▬ David Persse

▬ Linda Quan

▬ Rienk Rienks

▬ Justin Scarr

▬ Gert-Jan Scheffer

▬ Paul Sirbaugh

▬ Luiz Smoris

▬ Martin Stotz

▬ David Szpilman

▬ Andreas Theodorou

▬ Wolfgang Ummenhofer

▬ Wiebe de Vries

(4)

6.1 Overview

Paul Pepe and Joost Bierens

The Task Force on Resuscitation for the World Congress on Drowning 2002 was comprised of some of the world‘s recognised experts in resuscitation medicine.

Cited at the conference as the Drowning Resuscitation Dream Team, this group of individuals represented multiple continents, disciplines and international or- ganisations.

Task Force members had backgrounds from anaesthesia, critical care, emergency medicine, internal medicine, paediatrics, public health, pulmonary medicine, surgery, general practice and several other disciplines. Most of the members of the Resuscitation Task Force remain currently active as scientific advisors, committee members and consensus developers for several of the ma- jor resuscitation and resuscitation research-related organisations including the International Liaison Committee on Resuscitation, the American Heart Association, the Australian Resuscitation Council, the European Resuscitation Council, the International Lifesaving Federation, the International Committee on Resuscitation, the American Academy of Pediatrics, the Royal Lifesaving Society, the American College of Emergency Physicians and the National Association of EMS Physicians, as well as the National Institutes of Health and Centers for Disease Control and Prevention.

The expertise, experience and credibility of this task force are significant and the knowledge elements that they brought to the World Congress on Drowning 2002 were not only based on long-standing personal experience with the chal- lenges of drowning events, but also on the most up-to-date scientific evidence and consensus available.

In that respect, the Resuscitation Task Force had some unique advantages.

Much of the scientific data and conclusions from these deliberations could be

immediately derived and extrapolated from recent international consensus con-

ferences on resuscitation and the resultant published proceedings. Almost all of

the task force members had participated in these conferences and subsequent

collation of the information. A key example was the international guidelines

on cardiopulmonary resuscitation published recently by the American Heart

Association in conjunction with ILCOR in the year 2000. During the develop-

ment process of those guidelines, the world literature on resuscitation was scien-

tifically evaluated and weighed by international experts, including the available

information on drowning resuscitation. This experience helped to expedite the

process for the task force and also strengthened and expedited the consensus

regarding the final conclusions and recommendations.

(5)

6.1.1 Specific Focus of the Task Force

The delegated focus of this task force was the prehospital (out-of-hospital) set- ting where, of course, most drowning incidents occur, and where, presumably, most resuscitation efforts should take place. The task force was asked to evaluate multiple overlapping issues in drowning resuscitation, including:

▬ The key role of lay persons and their actions (on-scene CPR) Jane Wigginton and Paul Pepe (USA), lead authors

▬ Basic rescuer actions (basic life support) Ahamed Idris (USA), lead author

▬ Automated defibrillators in the aquatic environment Stephen Beerman (Canada), lead author

▬ Positioning the drowning victim (rescue and spinal considerations) Anthony Handley (UK) and David Szpilman (Brazil), lead authors

▬ Invasive life support (advanced life support) Volker Wenzel (Austria), lead author

▬ The long Q-T syndrome in drowning incidents (prevalence and implica- tions)

Alfred Bove (USA) and Rienke Rienks (the Netherlands), lead authors

▬ Paediatric considerations (physiology and anatomy) Robert Berg (USA), lead author

▬ Prognosis and termination of resuscitation (age, timing, physiology and tem- perature considerations)

Martin Nemiroff (USA), lead author

▬ Special resuscitation circumstances (unusual rescue situations) Peter Morley (Australia), lead author

▬ Several case reports of extreme situations (lessons that can be learned) Martin Stotz, Wolfgang Ummenhofer (Austria), Gert-Jan Scheffer (The Neth- erlands) and David Spzilman (Brazil), lead authors

In addition to these primary medical issues, the charge for the group also in- cluded the development of a first aid course for the aquatic environment as well as the development of standardised nomenclature and mechanisms for data col- lection and reporting related to drowning events:

▬ First aid course for the aquatic environment (recommended actions for by- standers)

David Szpilman (Brazil), lead author

▬ Utstein-Style template for drowning (standardised nomenclature and mech- anisms for data collection and reporting)

Ahamed Idris (USA), lead author

It should be noted that the consensus on this priority project (standardised

nomenclature and reporting) has now been published as an international

consensus in [1] and [2] as well.

(6)

In the following chapters, the main findings and conclusions of the task force will be reviewed in detail. But first, we provide an executive summary of these conclusions in the following chapter.

References

1. Idris A, Berg R, Bierens J, et al. (2003) ILCOR Advisory Statement. Recommended guidelines for uniform reporting of data from drowning: The Utstein style. Resuscitation 59:45−57

2. Idris AH, Berg RA, Bierens J, et al. (2003) Recommended guidelines for uniform reporting of data from drowning: The Utstein Style. Circulation 108:2565−2574

6.2 Consensus and Recommendations

Paul Pepe and Joost Bierens 6.2.1

Overview

One of the overall conclusions of this group is that, apart from the need for im- mediate and rapid resuscitative actions by on-scene bystanders (be they pro- fessional or lay persons), data are lacking regarding the optimal resuscitative management for victims experiencing a drowning incident. Therefore, a host of research efforts need to be initiated, starting with the development of standard- ised definitions and nomenclature for information to be collected and, in turn, standardised reporting mechanisms for these data.

Nevertheless, there is substantial empirical experience with drowning events and given the available data and collective experience of the task force members, the following recommendations should be highlighted for the time being.

6.2.2 Main Conclusions and Recommendations from the Task Force on Resuscitation

Basic resuscitation skills must be learned by all volunteer and professional res- cuers as well as lay persons who frequent aquatic areas or supervise others in a water environment.

The instant institution of optimal first aid and resuscitation techniques is the most important factor to ensure survival after a drowning event has occurred.

Professional rescue organisations and other groups involved in the aquatic en-

vironment should promulgate this concept and promote widespread CPR train-

ing. Resuscitation organisations, and in particular those related to International

Liaison Committee on Resuscitation (ILCOR), as well as professional rescue or-

ganisations and other groups who frequent aquatic areas, must promote training

(7)

programs in first aid and basic life support for anyone who frequently visits or is assigned to work in the aquatic or other water environment.

There needs to be uniform use of standardised definitions and nomenclature for data to be collected for drowning incidents, and, in turn, there also needs to be standardised reporting mechanisms for these data.

To increase the understanding of the dying process and the resuscitation po- tential in drowning, a uniform reporting system must be developed and used for the registration of resuscitation of drowning. International resuscitation organi- sations, such as ILCOR-related organisations and medical groups, must estab- lish a uniform reporting system, facilitate its use, be involved in the analysis of the data and support recommendations based on the resultant studies.

Consensus process: These conclusions were developed by the Task Force in consensus and then presented multiple times at the World Congress on Drowning in 2002 and later at the 2002 meeting of the European Resuscitation Council (ERC) and the International Liaison Committee for Resuscitation (ILCOR), as well as multiple subsequent relevant national venues and meetings in the US and Europe without any signifivant objection or modification. The recommendation for the standardisation was formally adopted by ILCOR and its member organisations.

6.2.3 The Critical Role of Lay Persons

and Their Actions in Drowning-Related Incidents

6.2.3.1 Conclusions

Several studies now confirm that, most lives are indeed saved by the immediate action of on-scene bystanders (be they lay persons or professional rescuers).

Relatively-speaking, without such immediate first aid and basic cardiopul- monary resuscitation (CPR) techniques, subsequent advanced and invasive life support techniques appear to be of little value in almost all cases.

The data supporting these conclusions were originally derived from two large studies of children, but preliminary information involving adult cases also support these conclusions.

Not enough people know or perform basic CPR, particularly when consider- ing the high incidence of drowning in children less than 5 years of age and the low frequency of CPR performed by parents who witness cardiopulmonary ar- rest due to drowning of their own child.

6.2.3.2

Recommendations

Additional research and public health initiatives need to be implemented to

increase the probability that there will be immediate performance of CPR and

other first aid techniques at every drowning incident.

(8)

Additional research should attempt to delineate those aspects of CPR that are most effective, be they rescue breaths, chest compressions, variable combina- tions of these techniques, or other potential interventions by on-scene rescuers.

Subsequent research should examine new techniques for training lay per- sons in CPR that will be more easily taught, performed and retained as a learned skill.

Consensus process: These conclusions and recommendations were developed by the authors of the relevant study and were then accepted by the Task Force on Resuscitation for presentation to the main body of the World Congress on Drowning. These conclusions were then presented multiple times at the World Congress on Drowning in 2002 and later at the 2002 meeting of the ERC and the ILCOR, as well as multiple subsequent relevant national venues and meetings in the US and Europe without any significant objection or modification.

6.2.4 Basic Life Support for Drowning Victims

There is no need to clear the airway, no need to perform the so-called Heimlich manoeuvre, and no need to perform a pulse check if the basic life support (BLS) provider is a lay rescuer. A traditional healthcare provider who checks pulses routinely in their professional activities may do so, but should not focus on this action if other signs of absent circulation are present.

Without oxygen supplementation, tidal volumes provided by bag-valve-mask (BVM) device, mouth-to-mouth or mouth-to-mask (unprotected airway) should be 10 ml/kg or, in most situations, enough to make the chest wall rise.

If supplemental oxygen is being used, however, this tidal volume may be re- duced somewhat to 6−7 ml/kg in most cases to diminish the risk of gastric insuf- flation.

Although chest compressions in those with circulatory arrest should be tran- siently interrupted to deliver breaths to the patient, every effort should be made to minimise this period of no compressions and every effort should be made not to frequently interrupt chest compressions.

In the situation of circulatory arrest, the number of breaths per minute may be less than currently recommended (15 compressions and two breaths), even in the case of drowning, and particularly with hypothermic conditions.

6.2.4.2

Recommendations

Researchers need to investigate alternative ventilatory techniques such as the

active-compression decompression pump and inspiratory threshold devices or

other novel techniques that will produce negative intrathoracic pressures such

as a phrenic nerve stimulator.

(9)

Future research considerations should include an evaluation of appropri- ate compression-to-ventilation ratios in drowning incidents (and particularly in hypothermic conditions) and they should evaluate optimal tidal volumes for drowning events in view of the unique pathophysiology and alveolar effects of inhaled liquids.

Consensus process: These conclusions and recommendations were developed largely from the previous recommendations of ILCOR and the American Heart Association (AHA) and were accepted by the Task Force on Resuscitation and then presented multiple times at the World Congress on Drowning in 2002 and later at the 2002 meeting of the ERC and the ILCOR, as well as at multiple subse- quent relevant national venues and meetings in the US and Europe without any signifivant objection or modification.

6.2.5 Automated Defibrillators in the Aquatic Environment

While ventricular fibrillation (VF) is an uncommon complication of drowning, especially in children, it can be a precipitating event on occasion.

VF occurs wherever persons at risk for sudden cardiac death are located and the aquatic environment is a frequented destination for persons of all ages, in- cluding such at-risk persons.

Therefore, by being a common gathering place for adults (and adults who su- pervise children), the aquatic environment is a reasonable target area for plan- ning for the performance of cardiopulmonary resuscitation (CPR) and, in turn, the use of automated external defibrillators (AED), which, today, is considered a key part of CPR.

6.2.5.2

Recommendations

Aquatic areas are important target areas for stationing CPR providers and AEDs, especially if the aquatic locations are distant from responding rescuers or if they are visited by large numbers of persons, be they swimmers or otherwise.

Consensus process: These conclusions and recommendations were developed

largely from an ad hoc working group of World Congress participants and the

conclusions then presented multiple times at the World Congress on Drowning

in 2002 and later at the 2002 meeting of the ERC and the ILCOR, as well as at mul-

tiple subsequent relevant national venues and meetings in the US and Europe

without any significant objection or modification.

(10)

6.2.6 Positioning the Drowning Victim

Evidence suggests that the best outcomes occur following drowning events when the recovery position for the drowning victim is one that is horizontal and par- allel to the shoreline, especially when there is a significant incline on the beach or shore.

It is unclear whether the left or right lateral position is more advantageous.

6.2.6.2

Recommendations

Future research in positioning needs to delineate the different aspects of posi- tioning, not only in terms of left versus right lateral positions, but also what to do during the various phases of salvage and recovery: during rescue, upon reaching land, during resuscitation and during recovery.

Future research efforts also need to include closer examination of the ab- solute need for spinal precautions and relative risk stratification under various circumstances.

Consensus process: These conclusions and recommendations were developed largely from the previous recommendations of ILCOR and the AHA and individ- ual research conclusions from the authors. These conclusions were accepted by the Task Force on Resuscitation and then presented multiple times at the World Congress on Drowning in 2002 and later at the 2002 meeting of the ERC and the ILCOR, as well as at multiple subsequent relevant national venues and meetings in the US and Europe without any significant objection or modification.

6.2.7 Invasive (Advanced) Life Support for Drowning

Few data support the absolute value of advanced life support (ALS) interven-

tions, but evolving data in the general population of cardiac arrest patients have

demonstrated the efficacy of inducing mild hypothermia to improve neurologi-

cal outcome. These observations have implications for traditional attempts to

re-warm resuscitated victims of drowning incidents. Empirically, with some

special considerations about ventilatory techniques, ALS interventions targeted

for the general cardiac arrest population should be used.

(11)

6.2.7.2

Recommendations

Recognising that bystander CPR is now the clear rate-limiting step in recovery and that hypoxia and hypoxemia are the main factors in the pathophysiology of drowning sequelae, extensive research is still needed, particularly in terms of proposed advanced therapeutic modalities such as tidal volumes, positive end- expiratory pressure (PEEP), respiratory rates, vasoactive agents, neuroprotec- tive agents, and therapeutic hypothermia.

Consensus process: These conclusions and recommendations were developed largely from the previous recommendations of ILCOR and the AHA and were accepted by the Task Force on Resuscitation and then presented multiple times at the World Congress on Drowning in 2002 and later at the 2002 meeting of the European Resuscitation Council and the International Liaison Committee for Resuscitation (ILCOR), as well as at multiple subsequent relevant national venues and meetings in the US and Europe without any significant objection or modification.

6.2.8 The Long QT Syndrome and Drowning

Long QT Syndrome is a risk for divers and swimmers, largely because of related exertion and other particular factors that may trigger a related arrhythmia in these circumstances.

6.2.8.2

Recommendations

Individuals with documented long QT syndrome (LQTS), even those with an implanted cardioverter-defibrillator, or those who have experienced potentially- related syncope or episodes of ventricular fibrillation should be advised against swimming or diving.

During the medical examination of (aspiring) scuba divers, it is recommend- ed that specific inquiries be made about any potentially related symptoms or the occurrence of sudden death among family members.

Consensus process: These conclusions and recommendations were developed

largely from an ad hoc group (comprised of the authors) who then presented

these recommendations at the World Congress on Drowning in 2002 without any

significant objection or modification.

(12)

6.2.9 Paediatric Considerations in Drowning

Drowning is one of the most common causes of death for children, especially for those aged 1−5 years.

With the exception of the usual caveats about body size and proportions and increased susceptibility to temperature extremes, there are no significant differ- ences that can be delineated at this time between adults and children in terms of the special circumstances of drowning.

Hypothermia may be therapeutic and thus it deserves further investigation as do concepts of how we provide re-warming.

Efforts aimed at the prevention of drowning deaths are currently weak worldwide as are efforts to promote CPR and its key role in paediatric drowning events.

6.2.9.2

Key Recommendations

There needs to be more prospective, population-based studies of drowning in children looking at the epidemiology, management and outcome predictors for this major public health problem.

There needs to be consideration of special interventions (that is, child-specif- ic, targeted hypothermia techniques) and special pharmacological needs (such as dobutamine) in future research efforts.

There is a need for more focused training and public education about the key role of CPR in paediatric drowning incidents.

Consensus process: These conclusions and recommendations were developed largely from the previous recommendations of ILCOR and the AHA and were accepted by the Task Force on Resuscitation and then presented multiple times at the World Congress on Drowning in 2002 and later at the 2002 meeting of the ERC and the ILCOR, as well as at multiple subsequent relevant national venues and meetings in the US and Europe without any significant objection or modi- fication.

6.2.10 Termination of Resuscitation Efforts

6.2.10.1 Conclusions

Current data about futility of resuscitation efforts are limited, not absolute and

the prognosis can be multi-factorial.

(13)

Although there are rare exceptions, almost all neurologically-intact survi- vors, including cold water victims, are resuscitated within 1 hour of the initiat- ing event.

Almost all normothermic adult patients are resuscitated within 25 minutes of the initiation of advanced life support techniques.

Water temperature below 21°C and younger age are correlated with improved prognosis.

6.2.10.2

Recommendations

Future research efforts should attempt to delineate the circumstances and appli- cable stratifications for the futility of continued resuscitation efforts following drowning incidents.

In addition to demographic information and water temperature considera- tions, future research efforts should determine maximum time intervals for re- suscitation efforts under these various circumstances and stratifications, partic- ularly with any new proposed neuro-protective or resuscitative interventions.

Consensus process: These conclusions and recommendations were developed by the authors of the relevant studies and were then accepted by the Task Force on Resuscitation for presentation to the main body of the World Congress on Drowning. These conclusions were then presented multiple times at the World Congress on Drowning in 2002 and later at the 2002 meeting of the ERC and the ILCOR, as well as multiple subsequent relevant national venues and meetings in the US and Europe without any significant objection or modification.

6.2.11 Unusual Rescue Circumstances, Considerations and Case Studies

6.2.11.1 Conclusions

A special attribute frequently differentiating drowning incidents from most oth- er resuscitation situations is the occasionally odd location of the event (such as buckets, toilets, tubs, pools, floods, storm surges, culverts, lakes, tanks, reser- voirs, storm drains, rivers or oceans), all providing unique challenges and often special coordination with other (non-healthcare) professionals as rescuers.

The association of other predisposing illnesses (particularly in the elderly)

and also associated sequelae (for example, ensuing or accompanying injuries)

also make this a special type of resuscitation event.

(14)

6.2.11.2

Recommendations

Whenever and wherever possible, epidemiological studies are recommended that track drowning circumstances, associated illnesses and injuries, and other related sequelae and associated hazards.

There should be anticipation, pre-planning, and follow-up of joint training needs for all potential rescuers in terms of the unique situations that may be encountered and associated with drowning events.

Consensus process: These conclusions and recommendations were devel- oped by the authors of the relevant section materials and were then accepted by the Task Force on Resuscitation for presentation to the main body of the World Congress on Drowning.

6.2.12 Utstein-Style Guidelines for Drowning-Related Incidents

6.2.12.1 Conclusions

Among a myriad of other consensus-based terms, drowning is now defined as a process of experiencing respiratory impairment from submersion/immersion in liquid. Implicit in this definition is that a liquid/air interface is present at the entrance of the victim‘s airway, thus, preventing the victim from breathing air.

A person may live or die after this process has occurred, but all who experience this process have had a drowning incident.

Improved validity, clarity, and data compatibility of future scientific investi- gations of drowning will improve our knowledge base, improve epidemiological stratification, improve appropriate treatment of victims of drowning and, ulti- mately, save lives.

6.2.12.2

Recommendations

To increase the understanding of the incidence, epidemiology, demography, risks, sequelae and outcomes of drowning-related events and to better under- stand the effects and resuscitation potential of various interventions, a uniform reporting system must be developed and used for the registration and study of drowning events.

Resuscitation organisations, and in particular those related to ILCOR, as well

as rescue organisations and other groups who frequent aquatic areas, must pro-

mote and facilitate the concept that there needs to be uniform use of standard-

ised definitions and nomenclature for data to be collected following drowning

incidents. In turn, there also needs to be standardised reporting mechanisms for

these data and scientific analysis of these data.

(15)

Therefore, all related organisations should adopt the consensus guidelines developed (see previous references).

Consensus process: These conclusions and recommendations were developed by the authors of the relevant publications mentioned previously and were then accepted by the Task Force on Resuscitation for presentation to the main body of the World Congress on Drowning. The special working group involved key members of the Task Force on Resuscitation and Task Force on Epidemiology and other invited specialists from key organisations such as ILCOR, the AHA, the Australian Resuscitation Council and the ERC. These conclusions were then presented multiple times at the World Congress on Drowning in 2002 for feed- back and later at the 2002 meeting of the ERC and the ILCOR, as well as multiple subsequent relevant national venues and meetings in the US and Europe without any significant objection or modification. They have now been published in key scientific journals as noted previously.

6.3 The Critical Role of Lay Persons

and Their Actions in Drowning Incidents Jane Wigginton, Paul Pepe, Denise Mann, David Persse and Paul Sirbaugh

It has been well-accepted for many years that most victims of critical drowning events will require instant on-scene medical attention such as the immediate performance of cardiopulmonary resuscitation (CPR) techniques by bystanders [1, 2]. However, the relative contribution of those bystander actions in drowning events has not yet been explicitly delineated.

6.3.1 Background

In most day-to-day situations, basic CPR performed by bystanders is considered to be a somewhat effective intervention, but only as a temporising action used to maintain some degree of critical tissue perfusion prior to arrival of a defibrilla- tor in the patient with sudden cardiac death [3]. In other circumstances, it is also accepted as a way to maintain some limited form of circulation while advanced life support (ALS) actions are taken. Therefore, while there may be occasional exceptions, in general, basic CPR is not considered a definitive therapy in itself, especially for the majority of survivable sudden cardiac deaths.

In contrast to sudden cardiac death events, however, defibrillation is rarely

needed in drowning incidents, particularly in the case of children [4, 5]. Also, be

it for cardiac arrest or drowning, the scientific basis for most ALS interventions

has been limited largely to laboratory evidence and some preliminary clinical

data [3, 6−8]. Therefore, the role of basic CPR in drowning events has yet to be

(16)

defined, either as a definitive therapy or as a temporising intervention that is provided as a bridge to ALS.

In addition, it has not been clear whether the key action in drowning is sim- ply rescue breathing. It may also be that chest compressions or some other type of aggressive stimulation is the key intervention. Specifically, it is not known whether chest compressions alone could be efficacious and what the relative con- tributions of chest compressions should be under various circumstances [9].

The difficulty with answering these questions is that drowning events, par- ticularly those occurring in children, are sudden, unanticipated and emotional events, often occurring in fairly uncontrolled settings. Even the need for full CPR procedures (rescue breathing and compressions) may be more difficult to assess, especially since respiratory arrests usually lead to cardiac arrest and by- standers may not be able to distinguish pulselessness. Not only are the potential witnesses unlikely to recall the exact actions taken and the sequencing of those actions, but even the rescuers themselves may have recall problems and uncer- tainty about what they actually did. This problem is often compounded by the re-telling of the event to a series of professional responders, perhaps beginning with lifesavers and firefighters as first responders and then continuing on to ambulance personnel and the first receiving in-hospital emergency personnel.

Except in certain systems designed to collect data as optimally as possible, the exact actions of the bystanders are therefore unlikely to be well-recorded and the concomitant correlations with outcome difficult to establish.

Recognising these issues, several of the authors of this chapter undertook an initiative to improve data collection and correlation to outcome, particularly as it relates to drowning events in children to solve this puzzle [10]. The pro- spective, population-based study of paediatric (ages 0−14 years) drowning inci- dents, conducted in Houston, Texas (USA), between 1990 and 2000 inclusively, provides us with some additional insight into the problem of drowning and the critical role of bystander actions. The results corroborate previous studies in children and are compatible with preliminary studies involving adult as well as paediatric populations [11, 12].

6.3.2 The Houston Paediatric Drowning Data

In an attempt to capture the magnitude of the problem of paediatric drowning

and examine elements that correlated with risk and outcome, investigators con-

ducted an 11-year prospective population-based study of drowning incidents in

the City of Houston, a municipality of about a 1.8-million resident population

and 565 square miles (nearly 1000 square kilometres). The at-risk population

(ages 0−14 years) averaged 418,000 during the decade of study. An average of 43

drownings occurred each year, making an annual incidence of 10.3 per 100,000

at risk. Two-thirds of all serious drowning incidents requiring a 9-1-1 (EMS sys-

tem) response, occurred in the children (0−14 years) and 71% of those occurred

in children less than or equal to 5 years of age (annual incidence of 18.3 per

(17)

100,000 at risk). In some years, this 0−5 years category accounted for as many as 87% of the paediatric cases.

Of the total number of 473 serious drowning cases in children 0−14 years of age requiring an EMS response, two-thirds of these clearly required some type of resuscitative effort. Of the 300 total cases requiring resuscitation, 101 died and two-third of deaths occurred in those less than or equal to 5 years of age. Also, two-thirds of the deaths occurred following pool incidents.

Perhaps the most impressive piece of information was the impact of bystand- er CPR. Half of the drownings received CPR by bystanders and 79% of those receiving bystander CPR survived to hospital discharge (97% neurologically in- tact). Most of the patients responded to bystander resuscitative efforts within a very short period of time to some degree or another and if the patient was still apneic and pulseless when the EMS rescuers arrived, only 5% responded to re- suscitation and of these none remained neurologically intact.

Based on data collection projects conducted prior to the current study, there had been suspicion that many children receiving CPR may not have needed that intervention because patients were awakening and pulsing when respond- ing rescuers arrived. This raised the concern that there was overzealous initia- tion of CPR by bystanders in certain cases for which it may not really have been needed. However, this concern was eliminated by a strict set of criteria in which the patients included as ‘requiring resuscitation’ had to be those reported by all available witnesses at the scene as clearly being unresponsive, lifeless, apneic, cyanotic or those later found to have chest roentgenogram and laboratory or physiological abnormalities consistent with water aspiration. These reports were obtained by a designated rescuer who conducted intensive follow-up interviews to document the strict criteria. Therefore, this information appears to be quite reliable and the remaining 173 cases of drowning not reported as requiring CPR may have been more serious than previously thought, but simply excluded be- cause the investigators could not document the required criteria to designate these as true resuscitation cases. In essence, this means that survival rates may be even better than the results reported here.

6.3.3 Discussion

This decade-long, population-based study demonstrated most strikingly that

bystander CPR appears to be the most definitive action for children with serious

drowning incidents requiring resuscitative efforts. Other studies support this

conclusion [11, 12]. A previous study from Southern California, by Kyriacou,

corroborates the same observations in children [11] and a recent report from

Brugge, Belgium, found similar findings in adults [13]. In that Belgian study,

Hooft studied 103 drowning incidents occurring between 1991−1996. The mean

age of this group was 49 years and among the 26 patients receiving CPR from

bystanders, only eight ultimately survived and only five had a good neurological

outcome. Of these five, four had return of spontaneous circulation prior to the

initiation of advanced life support interventions. Of the 76 patients not receiv-

(18)

ing bystander CPR, none survived despite the implementation of such advanced interventions in most cases.

Therefore, performance of CPR by bystanders, usually lay persons, appears to be the necessary factor in terms of determining intact survival for the pae- diatric drowning victim. Relatively-speaking, without such immediate first aid and basic CPR techniques, subsequent advanced and invasive life support tech- niques appear to be of little value in almost all cases.

6.3.4 The Need for More CPR Training

Although the frequency of CPR is slightly higher in the settings of drowning (usually public places), it should probably be even higher than portrayed in this and other studies. Simply put, not enough people know or perform basic CPR, particularly when considering the low frequency of CPR performed by parents who witness the cardiopulmonary arrest of their own child [4].

Considering that the frequency of CPR training and performance is generally low in most venues, more aggressive campaigns to require CPR training for all persons (for example, required CPR training in the high schools, in the work- place or to acquire a driver‘s license as they do in some countries) must be con- ducted. Additional research and public health initiatives need to be implement- ed to increase the probability that there will be immediate performance of first aid techniques and CPR at every drowning incident. Also, additional research should attempt to delineate those aspects of CPR that are most effective, be they rescue breaths, chest compressions, variable combinations of these techniques, or other potential interventions by on-scene rescuers. In addition, subsequent research should examine new techniques for training lay persons in CPR that are shorter and more easily taught, performed and retained as a learned skill.

References

1. Haynes BE (2000) Near drowning. In: Tintinalli JE, Kelen GD, Stapczynski JS (eds) Emergency medicine. McGraw-Hill, New York, pp 1278-1279.

2. Modell JH (1993) Drowning. N Engl J Med 328:253−258

3. Cummins R, Ornato J, Thies W, Pepe P (1991) Improving survival from sudden cardiac arrest: the chain of survival concept. A statement for health professionals from the Advanced Cardiac Life Support Subcommittee and the Emergency Cardiac Care Committee, American Heart Associa- tion. Circulation 83:1832−1847

4. Sirbaugh P, Pepe P, Shook J, et al. (1999) A prospective, population-based study of the demo- graphics, epidemiology, management, and outcome of out-of-hospital pediatric cardiopulmonary arrest. Ann Emerg Med 33:174−184

5. Quan L, Kinder D (1992) Pediatric submersions: prehospital predictors of outcome. Pediatrics 90:909−913

6. Stiell IG, Wells GA, Field B, et al. (2004) Advanced life support in out-of-hospital cardiac arrest. N Engl J Med 351:647−656

7. Wenzel V, Krismer AC, Arntz HR, et al. (2004) A comparison of vasopressin and epinephrine for out-of-hospital cardiopulmonary resuscitation. N Engl J Med 350:105−113

(19)

8. Pepe P, Abramson N, Brown C (1994) ACLS − Does it really work? Ann Emerg Med 23:1037−1041 9. Roppolo L, Wigginton JA, Pepe PE (2004) Emergency ventilatory management as a detrimental

factor in resuscitation practices and clinical research efforts. In: Vincent JL (ed) 2004 Yearbook of Intensive Care and Emergency Medicine. Springer, Berlin, pp 139−151

10. Pepe PE, Wigginton JG, Mann DM, Persse DE, Sirbaugh PE, Berg RA (2002) Prospective, decade-long, population-based study of pediatric drowning-related incidents. Acad Emerg Med 9:516−517

11. Kyriacou D, Arcinue E, Peek C, Kraus J (1994) Effect of immediate resuscitation on children with submersion injury. Pediatrics 94:137−142

12. Goh SH, Low B (1999) Drowning and near-drowning − some lesions learned. Acad Med Singa- pore 28:183−188

13. Hooft P (2002) The influence of lay cardiopulmonary resuscitation on outcome after cardiopulmonary arrest due to drowning. Book of abstracts, World Congress on Drowning, Amsterdam, p 164

6.4 Basic Life Support for Drowning Victims

Ahamed Idris

The most important consequence of submersion without ventilation is hypox- emia [1, 2]. The duration of submersion and accompanying hypoxemia are the most critical factors in determining the outcome of the victim. Thus, logically, oxygenation, ventilation, and critical organ perfusion should be restored as soon as possible.

6.4.1 Basic Life Support (BLS) Sequence

The first and most important treatment of the drowning victim is immediate mouth-to-mouth ventilation, which has been shown to have a positive effect on outcome [3]. Rescue breathing should be started as soon as the airway of the victim can be opened. Ventilation devices that provide oxygen supplementation should be used as soon as they are available and a call should be made to the emergency medical system (EMS) as soon as possible.

There is no need to clear the airway of aspirated water. Some victims aspirate nothing because of laryngospasm and only a modest amount, at most, is aspi- rated by the majority [1, 2]. Abdominal thrusts (Heimlich manoeuvre) should not be used routinely because it increases the risk of regurgitation and aspira- tion and it also delays initiation of ventilation [1].

If signs of circulation are absent, chest compressions should be started im-

mediately [4]. If an automatic external defibrillator (AED) is available, it should

be applied to assess the cardiac rhythm of the victim. If a shockable rhythm is

present, defibrillation should be attempted [4].

(20)

6.4.2 Rescue Breathing Techniques

Recent changes have been made to BLS guidelines for typical cardiac arrests.

Among these are modifications in the approach to rescue breathing and bag- valve-mask (BVM) ventilation. Gastric inflation frequently develops during mouth-to-mouth ventilation as air being forced into the oropharynx can travel either down the trachea or oesophagus. Gastric inflation can produce serious complications such as regurgitation, aspiration or pneumonia [1]. If overzeal- ously done, it also can increase intragastric pressure, elevate the diaphragm, re- strict lung movement, and decrease respiratory system compliance. Gastric in- flation generally occurs when the pressure in the oesophagus exceeds the lower oesophageal sphincter opening pressure. This causes the sphincter to open, so air delivered during rescue breaths may more likely enter the stomach, instead of the lungs. During cardiac arrest, the likelihood of gastric inflation increases because the lower oesophageal sphincter relaxes. Factors that contribute to a gastric inflation during rescue breathing include: obstructed airway (tongue, poor positioning), a short inspiratory time (rapidly delivered breath), a large tidal volume, and a high peak airway pressure (usually brought on by the previ- ous three factors). Therefore, actions that can open the airway more (better po- sitioning, oral airway devices, jaw thrusts, chin lifts), slow ventilatory delivery time (slow steady breath delivered over 2 seconds) and better control over the tidal volume delivered are important as is cricothyroid membrane pressure to compress the oesophagus.

This is most of all important in drowning victims where loss of surfactant and acute pulmonary impairments will lead to a decreased pulmonary compli- ance.

6.4.3 Tidal Volume Considerations

Recent recommendations for tidal volumes and inspiratory times for ventila- tion have been modified [4]. A tidal volume of approximately 10 ml/kg (approxi- mately 700−1000 ml for most adult persons) is delivered slowly and steadily over 1.5−2.0 seconds. This usually leads to observation of a well-defined chest rise when mouth-to-mouth breathing or mouth-to-mask breathing is provided with- out oxygen supplementation (Class IIa recommendation) [4].

However, in view of the unprotected airway and risk for gastric insuffla-

tion, when supplemental oxygen is available, a tidal volume of 6−7 ml/kg (ap-

proximately 400−600 ml for most adult persons) may be preferable. This breath

should be delivered over 1.5−2.0 seconds until a chest rise is observed. This

would most typically be applicable when rescuers are using a BVM device or a

mouth-to-mask device with oxygen supplementation that provides an inspired

concentration of oxygen of 40% or more (Class IIb recommendation) [4]. While

these tidal volumes may not be as applicable in the drowning scenario, in which

surfactant loss and other physiological sequelae may make alveolar recruitment

(21)

more difficult, there are no studies that would confirm the need for an alterna- tive approach [1].

6.4.4 Pulse Check

The pulse check has been deleted from the assessment steps performed by lay rescuers [4]. Lay rescuers should check for signs of normal breathing, coughing or movement to determine the presence or absence of circulation. Healthcare providers accustomed to taking pulses can perform a pulse check, but they should do so in conjunction with assessment of signs of breathing, coughing or movement (Class IIa recommendation) [4].

6.4.5 Chest Compressions

The recommended compression rate for one- and two-rescuer adult CPR has been increased to 100 compressions per minute (Class IIb recommendation) [4]. However, in the year 2000, the ratio of 15 compressions to two ventilations was recommended for both one- and two-rescuer CPR for the adult victim with an unprotected (non-intubated) airway (Class IIb Recommendation) [4].

Recommendations for children remained at 5:1, but these practices, both for adults and children, are being re-evaluated.

Although chest compressions in those with circulatory arrest should be transiently interrupted to deliver breaths to the patient during BLS, every effort should be made to minimise this period of no compressions and every effort should be made not to frequently interrupt chest compressions. Although posi- tive pressure breaths may inflate lung zones, they may also increase intrathorac- ic pressure enough to impede venous return. Also, stopping to ventilate impairs coronary perfusion [5−7]. It may take 10−15 compressions to return to previous levels of coronary perfusion achieved when compressions are interrupted to de- liver a breath. Therefore, with current techniques, most of the compression cycles are used to return to the pressure head lost when compressions were halted.

In fact, in the situation of circulatory arrest, the number of breaths required

per minute may be much less than currently recommended, even in the case

of respiratory impairment such as drowning, and particularly when there are

hypothermic conditions due to lower metabolism and less carbon dioxide ex-

cretion. More recently, recommendations are evolving and leaning toward a

higher ratio of compressions to ventilations such as 50:2 or 30:2 for adults and

15:2 for children [5, 8]. Readers should refer to the most recent guidelines for

compression−ventilation ratios which are due to be published in December of

2005. Also, one should differentiate between those with pulses (who will need

more ventilation) and those in circulatory arrest. Ventilation should match per-

fusion.

(22)

Chest compression-only CPR has been recommended in certain circum- stances [4] such as those in which a rescuer is unwilling or unable to perform mouth-to-mouth rescue breathing (Class IIa recommendation) [4], or those in which dispatchers are providing instructions over the telephone to bystanders on-scene. The simplicity of this modified technique allows untrained bystand- ers to rapidly intervene (Class IIa recommendation) [4]. For teaching purposes, and during performance of CPR, audio timing prompts may help to achieve the required rate for the performance of chest compressions (Class IIb recommen- dation) [4].

6.4.6 Relief of Foreign-Body Airway Obstruction

It has been recommended that the guidelines sequence for management of air- way obstruction in unconscious adults should not be taught to the lay public [4]. Emphasis should be placed on continued effective chest compression, open- ing the airway and attempting ventilation (Class IIb recommendation) [4]. The healthcare provider, however, should continue to learn how to achieve relief of foreign body airway obstruction in both conscious and unconscious victims.

6.4.7 Conclusions and Recommendations

Researchers need to investigate alternative ventilatory techniques to inflate lung zones while minimizing the gastric insufflation and maximizing of venous re- turn. Interventions should be examined such as the active-compression decom- pression pump and inspiratory threshold devices or other novel techniques that will produce negative intrathoracic pressures such as a phrenic nerve stimulator [9].

Also, future research considerations should include an evaluation of appro- priate compression to ventilation ratios in drowning incidents, particularly in hypothermic conditions. Future drowning research should evaluate optimal tidal volumes for drowning events in view of the unique pathophysiology and alveolar effects of inhaled liquids.

References

1. Bierens JJLM, Knape JTA, Gelissen HPMM (2002) Drowning. Curr Opin Crit Care 8:578−586 2. Modell JH (1993) Drowning. N Engl J Med 328:253−258

3. Safar P, Escarraga LA, Elam JO (1958) A comparison of the mouth-to-mouth and mouth-to-airway methods of artificial respiration with the chest pressure arm-lift methods. N Engl J Med 258:671−677

4. Idris AH, Basic Life Support Subcommittee (2002) Basic life support and special situations.

American Heart Association Guidelines 2000 for cardiopulmonary resuscitation and emergen-

(23)

cy cardiovascular care − international consensus on science, August 22, vol 102 (Supplement I), pp 1−384

5. Roppolo LP, Wigginton JA, Pepe PE (2004) Emergency ventilatory management as a detrimental factor in resuscitation practices and clinical research efforts. In: Vincent J-L (ed.) 2004 Year- book of intensive care and emergency medicine. Springer, Berlin, pp 139−151

6. Koster RW (2003) Limiting ‚hands-off‘ periods during resuscitation. Resuscitation 58:275−276 7. Berg RA, Sanders AB, Kern KB, Hilwig RW, Heidenreich JW, Porter ME, Ewy GA (2001) Adverse

hemodynamic effects of interrupting chest compressions for rescue breathing during cardiopulmonary resuscitation for ventricular fibrillation cardiac arrest. Circulation 104:2465−2470 8. Babbs CF, Nadkarni V (2004) Optimizing chest compression to rescue ventilation ratios during

one-rescuer CPR by professionals and lay persons: children are not just little adults. Resuscita- tion 61:173−181

9. O‘Connor RE, Ornato JP, Wigginton JG (2003) Alternate cardiopulmonary resuscitation devices.

Prehosp Emerg Care 7:31−41

6.5 Automated External Defibrillators in the Aquatic Environment

Steve Beerman and Bo Løfgren

The use of the automated external defibrillator (AED) has become widely-adop- ted and has even become part of standard CPR training. This chapter discusses the issues of AED in the modern chain of survival, and, in particular, its poten- tial use in the aquatic environment.

6.5.1 Cardiac Arrest and Defibrillation

Early defibrillation is a key determinant of survival from cardiac arrest due to ventricular fibrillation (VF) [1−4]. Ventricular fibrillation is the initiating event in the majority of adult cardiac arrests out-of hospital and it is the presenting rhythm for about 30%−50% of cardiac arrest victims in the emergency medical systems (EMS) in major developed cities [1−3]. Fast rescuer response intervals increases the likelihood of the cardiac arrest victim having VF at the time of arrival and concomitant rapid defibrillation improves the chances of survival, especially with performance of CPR by bystanders [1−4]. Broadening access to AEDs as well as training in AED use beyond health care professionals can help reduce the time to defibrillation and thus improve survival probabilities [2, 3, 5−14].

While untreated VF is a uniformly deadly event, VF is almost always revers-

ible with the immediate availability and use of a defibrillator [2]. However, since

most patients do not have immediate access to a defibrillator, resuscitation to

survival may depend on a series of critical interventions being performed. The

chain of survival metaphor has been used to describe this sequence of critical

interventions [1]. The traditional chain has four interdependent links: early ac-

cess (notification of emergency response dispatchers), early basic life support

(BLS) on CPR, early defibrillation (with AED or manual defibrillator), and early

(24)

advanced life support (ALS) with medications and advanced airways. However, immediate use within a minute or two of an AED may obviate the need for ALS and even BLS, as patients may even respond and awaken long before traditional professional rescuers arrive [2, 6].

Cardiac arrest associated with VF or ventricular tachycardia (VT) is rare in drowning victims [15−19]. There is very limited case study literature on the use and success of defibrillation in drowning cases. Most of the case reports in the medical literature of defibrillation in the aquatic environment were not related to drowning victims, but rather cardiac arrests from non-drowning causes.

Specifically, many aquatic facilities are associated with large public areas.

Cardiac arrest is more probable within high volume public areas [1−3, 11]. As a result, some aquatic facility staff members have placed AED equipment in or near aquatic areas in order to be prepared to respond to cardiac arrests due to VF and VT, not in the water, but at the edge of the water where many people gather, including those at risk for VF or VT.

6.5.2 AED and Defibrillation

Defibrillation is primarily intended to correct problems associated with most sudden cardiac arrest, specifically VF or VT. However, the AED has no positive impact on the outcomes for non-shockable rhythms in cardiac arrest [20]. An AED is a computerised defibrillator programed to recognise and shock either VF or VT. If the machine recognises either VT or VF in the victim, it will charge itself and indicate, usually by voice prompt, that a shock is advised.

When a shock is delivered to the heart, this will momentarily stop all elec- trical activity in the heart. This may terminate the VF or VT that was occur- ring. The natural pacemaker of the heart, the sino-atrial node, may then have a chance to take command and begin generating the impulses, which will start the normal pumping action at the heart. Sometimes multiple shocks are required to achieve this sequence of events.

The reliability of the AED is as good as any medical device can be [3]. The identification of VF is better than human interpretation and almost 100% spe- cific [2]. Technological advances have resulted in AEDs that are portable, safe, easy to use and easy to maintain with batteries that can last for years in stand-by conditions. It is logical that as they become less expensive, they are more likely to be placed in areas of public use [3, 11, 12]. Recent studies of defibrillation by the public at the Chicago airport showed remarkable save rates for VF (>75%) at nominal costs per life saved [2].

6.5.3 The AED in the Aquatic Environment

To achieve the earliest possible defibrillation, many organisations such as ca-

sinos, stadiums or airlines have created targeted AED training and rapid AED

(25)

access for security guards and flight attendants, achieving remarkable save rates and hundreds of lifesaving incidents since implementation in the late 1990s [2, 6−10]. In turn, lifesavers and those who live, work and play in the aquatic en- vironment have expressed interest in the use of AED to improve resuscitation outcomes in their targeted setting. Aquatic personnel should still appreciate that an AED is not necessarily a top priority equipment requirement due to the rela- tively low risk of a VF or VT event at a given site. However, an AED can be an appropriate adjunct to basic water rescue equipment, oxygen equipment, basic first aid and CPR equipment. Again, it is recognised that aquatic environments are a frequent venue for large numbers of people, as are recreation and fitness facilities, and events and activities that invite and attract people who may also be at risk for cardiac arrest. For all of these reasons, individuals and organisations providing supervision to aquatic environments, should have a keen interest in the availability of an AED for the aquatic settings and its environs.

Most drowning victims have healthy hearts that cease to function due to hy- poxia. The best approach in treating drowning victims is to prevent prolonged submersion, provide immediate CPR measures, ideally with high flow oxygen, and then, if available, an AED may be used, in accordance with the criteria of the manufacturer and the local response priorities. This may be helpful in the relatively unlikely case that the drowning victim has a cardiac arrest with VF or VT.

In 1999, the Medical Commission of the International Life Saving Federation (see

6.5.7

) recommended a statement on AED use by lifesavers.

The principles, stated in

_⊡ Table 6.1

, are a reasonable starting point for those seeking to prepare for AED use in the aquatic environment. In recent years, many lifesaving organisations have trained, placed and used AEDs in the aquat- ic environment. A critical appraisal of large cohort data from these initiatives will be extremely useful.

6.5.4 Barriers to AED Use

Early concerns about the use of AED on wet cardiac arrest victims have not been a problem in the field and there has not been any environmental specific risks reported. Although dry surfaces are preferred, this is a relative concern and not a contraindication to the use of AED. A quick drying of the pooled water from the chest prior to application of shock is recommended. At the time of this pub- lication, there has not been one report of dangerous conduction of shock from cardiac arrest victims through the adjacent wet surfaces. Testing by the manu- facturers confirms this safety issue. However, the AED is not recommended for in-water application. Nevertheless, it may be appropriate to apply an AED at the earliest convenient moment once the victim is placed on a hard surface.

Use of the AED in the aquatic environment is a concept that is gaining use as

the barriers of ideology, priority and economics are being challenged. Perceived

liability for rescuers misusing these devices, a near-impossibility, is being re-

placed by legal exposure for not having these lifesaving devices available. There

(26)

now exist very sound and well-established principles for decision-making, train- ing, use and reporting of AED, paving the way for their routine use in the aquatic and near-aquatic environment [3, 12, 21, 22]. Most victims of cardiac arrest are from adjacent land-based crowds and land-based associated recreation or fit- ness activities. The lifesaver or lifesavers may be conveniently located, trained

⊡ Table 6.1. Statement by the International Life Saving Federation, Medical Commission on automated external defibrillator (AED) use by lifesavers and lifeguards

1. Outcomes from drowning and water-related accidents can be tragic. The principle objective for lifesavers and lifeguards is to prevent, drowning and water-related accidents through education, supervision and rapid rescue response

2. The principle consequence of drowning is hypoxia. The provision of lifesavers and lifeguards with training and equipment for early recovery of victims from water is the highest priority

3. All lifesavers and lifeguards should receive training in basic life support (chain of survival, early access to EMS, airway management and CPR)

4. Early defibrillation in the management of cardiac arrest is effective in cases of VF and VT. When an arrest victim, in VF or VT, has early application of defibrillation, this is associated with conversion to sinus rhythm and to functional survival. VF and VT may be present in some drowning resuscitations when early recognition, speedy rescue and effective CPR with oxygen supplementation, has occurred. Early application of AED may be helpful in these cases

5. Advanced life support skills (defibrillation, medication and intensive care) may be part of the community response to cardiac arrest. It is appropriate for some lifesaving and lifeguard services to investigate AED use. This review should include investigations of other community AED providers, AED response times, frequency of cardiac arrests, supervision and management of AED, AED license requirements, cost/benefit analysis and outcomes studies. Decisions about the availability, placement, training and use of AED should be a community level decision based on the principles of the “chain of survival”, local resourc- es and community priority

6. Lifesaver and lifeguards may play a role in the delivery of AED if this is consistent with the support and service priorities of that community

7. If lifesavers or lifeguards will be delivering AED, they must receive appropriate training in the use of AED and the associated issues related to outcomes, stress and grief 8. National, regional and local lifesaving and lifeguarding organisations may choose to participate in the development of training policies for the use of AED by non-medical personnel, if and when communities choose to implement AED use by lifesavers or lifeguards. Lifesavers and lifeguard services are part of a community risk management and response plan, an integral part of a wider population safety network

9. Outcome studies of the application of AED by lifesavers and lifeguards in aquatic settings should be encouraged

EMS, emergency medical systems; CPR, cardiopulmonary resuscitation; VF, ventricular fibrillation;

VT, ventricular tachycardia.

(27)

and equipped to provide immediate care. Education about changes in AED and CPR training should be monitored and updated as needed. [22, 23].

6.5.5 Caveats

A significant percentage of cardiac arrest victims do not survive to hospital ad- mission [1]. Unsuccessful outcomes are usually more frequent than successful outcomes, regardless of the equipment available to assist assessment and treat- ment. Training in resuscitation, with or without adjunctive equipment, should include realistic rescuer expectations and critical incident debriefing education [22].

6.5.6 Conclusion

The AED may become an increasingly common link in the chain of survival within aquatic environments. Shockable rhythms in drowning victims are very rare and uncommonly cited in published drowning cardiac arrest papers and case reports. However, VF and VT may still be more likely to occur in areas adjacent to the water. Beaches, poolsides, lakesides and riverbanks are common attractions for human gatherings and VF and VT cases are more likely to surface wherever humans gather in large numbers. The assessment of the AED impact on outcomes in the aquatic environment and adjacent domains is a research pri- ority.

6.5.7 Website

International Lifesaving Federation − Medical Commission − www.ilsf/med

References

1. Cummins RO, Ornato JP, Thies WH, Pepe PE (1991) Improving survival from sudden cardiac arrest: the chain of survival concept. A statement for health professionals from the Advanced Cardiac Life Support Subcommittee and the Emergency Cardiac Care Committee, American Heart Association. Circulation 83:1832−1847

2. Caffrey SL, Willoughby PJ, Pepe PE, Bedker LB (2002) Public use of automated defibrillators. N Engl J Med 347:1242−1247

3. Weisfeldt M, Kerber RE, McGoldrick RP, et al. (1995) American Heart Association report on the public access defibrillation conference, Dec 8−10, 1994. Circulation 92:2740−2747

4. Hertlitz J, Bang A, Homberg M, et al. (1997) Rhythm changes during resuscitation from ventricular fibrillation in relation to delay until defibrillation. Resuscitation 34:17−19

(28)

5. Bunch TJ, White RD, Gersh BJ, et al. (2003) Long-term outcomes of out-of-hospital cardiac arrest after successful early defibrillation. N Engl J Med 348:2626−2633

6. Valenzuela TD, Roe DJ, Nichol G, et al. (2000) Outcomes of rapid defibrillation by security offic- ers after cardiac arrest in casinos. N Engl J Med 343:1206−1209

7. Page RL, Joglar JA, Kowal RC, et al. (2000) Use of automated external defibrillators by a U.S.

airline. N Engl J Med 343:1210−1216

8. Wassertheil J, Keane G, Fisher N, Leditschke JF (2000) Cardiac arrest outcomes at the Melbourne Cricket Ground and Shrine of Remembrance using a tiered response strategy − a forerunner to public access defibrillation. Resuscitation 44:97−104

9. MacDonald RD, Mottley JL, Weinstein C (2002) Impact of prompt defibrillation on cardiac arrest at a major international airport. Prehosp Emerg Care 6:1−5

10. O‘Rourke MF, Donaldson EE, Geddes JS (1997) An airline cardiac arrest program. Circulation 96:2849−2853

11. Becker L, Eisenberg M, Farhenbruch C, Cobb LA (1998) Public locations of cardiac arrest: implications for public access defibrillation. Circulation 97:2106−2109

12. Nichol, G, Valenzuela T, Roe D, et al. (2003) Cost effectiveness of defibrillation by targeted responders public settings. Circulation 108:697−703

13. Myerburg RJ, Fenster J, Velez M, et al. (2002) Impact of community-wide police car deployment of AED in survival from out-of-hospital cardiac arrest. Circulation 106:1030−1033

14. Watt DD (1995) Defibrillation by basic emergency medical technicians. Ann Emerg Med 26:635−639

15. Monolios N, Mackie I (1988) Drowning and near-drowning on Australian beaches patrolled by life-savers: a 10 year study 1973−1983. Med J Australia 148:165−171

16. Kuisma M, Suominen P, Korpela R, et al. (1995) Pediatric out-of-hospital cardiac arrest− epidemiology and outcome. Resuscitation 30:141−150

17. Sirbaugh PE, Pepe PE, Shook JE, et al. (1999) A prospective, population-based study of the de- mographics, epidemiology, management and outcome of out-of-hospital pediatric cardiopulmonary arrest. Ann Emerg Med 33:174−184

18. Orlowski JP, Szpilman D (2001) Drowning. Rescue, resuscitation, and reanimation. Pediatr Clin North Am 48:627-646

19. Modell JH (1993) Drowning. N Engl J Med 328:253−256

20. Pepe PE, Levine RL, Fromm RE Jr, et al. (1993) Cardiac arrest presenting with rhythms other than ventricular fibrillation: Contribution of resuscitation efforts toward total survivorship. Crit Care Med 21:1838−1843

21. Kloeck W, Cummins RO, Chamberlain D et al. (1997) An advisory statement from the Advanced Life Support Working Group of the ILCOR. Circulation 95:2183−2184

22. American Heart Association (2001) Fundamentals of BLS for healthcare providers. American Heart Association, Dallas, Texas, pp 37−55

23. Cobb LA, Fahrenbruch CE, Walsh TR, et al. (1999) Influence of CPR prior to defibrillation in patients with out-of-hospital ventricular fibrillation. JAMA 281:1182−1188